WESSEX DEANERY Guidelines for Work Place Based Assessments. The CCT in Anaesthetics Curriculum 2010 Updated Sept 2012

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1 WESSEX DEANERY Guidelines for Work Place Based Assessments The CCT in Anaesthetics Curriculum 2010 Updated Sept 2012 CT1 & CT2 (7-24 months) Basic Anaesthesia This document has been compiled by Drs Jon Chambers and Richard Jee and adapted by Drs Julie Onslow and Kathy Torlot. 1

2 This document is intended as a guide to the work placed based assessments (WPBAs) that are necessary for completion of each unit of training and has been updated following the publication by the Royal College of Anaesthetists of the Assessment Guidance (2010 Curriculum). The RCOA document has been summarised. For each unit of training there are a minimum number of WPBAs that are required. Each Unit of Training is prefaced by a number of Core Clinical Learning Outcomes. A minimum requirement for the ARCP is evidence that these have been satisfactorily achieved. There are a number of different types of WPBAs that each trainee should obtain. The mix will be different for each unit. These are: A Anaesthesia Clinical Evaluation Exercise [A-CEX] C Case Based Discussion [CBD] D Direct Observation of Procedural Skills [DOPS] L Anaesthesia List Management Assessment Tool [ALMAT] M Multi-source Feedback [MSF] S Simulation WPBAs must only be undertaken by those who are appropriately trained; if they are performed by others than consultants in anaesthesia, intensive care and pain medicine, a consultant must take ultimate responsibility for the assessment outcome and they should be countersigned by the educational superviser. Once the trainee has completed all the minimum clinical learning outcomes identified in The Basis of anaesthetic practice ( 0-6 months) and has obtained the IAC, they will move on to the remainder of Basic Level Training known as Basic Anaesthesia. This will provide a comprehensive introduction to all aspects of elective and emergency anaesthetic practice. The Basic anaesthetic units of training are: Airway management Critical incidents Day surgery General, urological and gynaecological surgery ENT, maxillo-facial and dental surgery Non-theatre/Transfer Obstetrics Orthopaedic surgery Paediatrics - Child protection Pain medicine Regional Sedation Trauma and stabilisation Intensive Care medicine will be delivered as a three month module. Please see Annex F CCT in Anaesthesia for Basic Level Training requirements. 2

3 Airway Management Minimum clinical learning outcomes: Must be achieved Able to predict difficulty with an airway at preoperative assessment and obtain appropriate help Able to maintain an airway and provide definitive airway management as part of emergency resuscitation Demonstrates the safe management of the can t intubate can t ventilate scenario Maintains anaesthesia in a spontaneously breathing patient via a facemask for a short surgical procedure [less than 30 mins] CBD Explains the methods commonly used for assessing the airway to predict difficulty with tracheal intubation (AM_BK_01) DOPS Able to maintain an airway and provide definitive airway management as part of emergency resuscitation A-CEX Maintains anaesthesia in a spontaneously breathing patient via a facemask for a short surgical procedure [less than 30 mins] SIM Demonstrates management of can t intubate, can t ventilate (AM_BS_10) MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 1 A-Cex, 1 DOPs and 1 CBD 3

4 Critical Incidents Minimum clinical Learning Outcomes: Must be achieved To gain knowledge of the principle causes, detection and management of critical incidents that can occur in theatre To be able to recognise critical incidents early and mange them with appropriate supervision To learn how to follow through a critical incident with reporting, presentation at audit meetings, and discussions with patients To recognise the importance of personal non-technical skills and the use of simulation in reducing the potential harm caused by critical incidents SIM Basic Competences for Critical Incidents Demonstrates the emergency management of the following critical incidents in simulation: 1. Cardiac and / or respiratory arrest 2. Unexpected Hypoxia with or without cyanosis 3. Unexpected increase in peak airway pressure 4. Progressive fall in minute volume during spontaneous respiration or IPPV 5. Fall in end tidal CO2 6. Rise in end tidal CO2 7. Rise in inspired CO2 8. Unexpected hypotension 9. Unexpected hypertension 10. Sinus Tachycardia 11. Arrhythmias [ST segment changes; sudden tachydysrhythmia; sudden bradycardia; Ventricular ectopics Ventricular tachycardia Ventricular Fibrillation] 12. Convulsions Demonstrate the management of the following specific conditions in simulation: 1. Aspiration of vomit 2. Laryngospasm 3. Bronchospasm 4. Tension Pneumothorax 5. Gas / Fat / Pulmonary embolus 6. Adverse drug reactions 7. Anaphylaxis 8. Transfusion of miss-matched blood or blood products 9. Malignant hyperpyrexia 10. Inadvertent intra-arterial injection of irritant fluids 11. High spinal block 12. Local Anaesthetic toxicity 13. Failed intubation 14. Difficulty with IPPV and sudden or progressive loss of minute volume It is not expected that trainees will formally demonstrate simulated management of more than a small number of these specific events but they must know the steps in managing all. MINIMUM REQUIREMENT = HAS BEEN TO THE NOVICE SIMULATOR COURSE 4

5 Day Surgery To gain knowledge, skills and experience of the perioperative anaesthetic care of ASA 1 and 2 patients presenting in a dedicated Day Surgery Unit involving a range surgical specialities [minimum three] Understand and apply agreed protocols with regard to patient selection and perioperative care of day surgery patients Understand the importance of minimising postoperative complications, such as nausea and pain, in patients who are returning home the same day Minimum clinical learning outcome: Must be achieved Knows the criteria for patient selection and the anaesthetic requirements for day surgical patients A-CEX Demonstrates appropriate anaesthetic management of ASA 1and 2 patients requiring day surgery (DS_BS_02) CBD Knows the criteria for patient selection and the anaesthetic requirements for day surgical patients MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 1 A-CEX, 1 DOPs and 1CBD 5

6 General, Urological and Gynaecological Surgery To gain knowledge, skills and experience of the peri-operative anaesthetic care of patients requiring elective and emergency general, urological and gynaecological surgery To gain understanding of the peri-operative management of patients requiring intra-abdominal laparoscopic surgery and the particular issues related to anaesthetic practice, demonstrating the ability to manage such straightforward cases in adults under distant supervision To be able to recognise and manage the peri-operative complications associated with intraabdominal surgery that are relevant to anaesthesia Minimum clinical learning outcomes: Must be achieved Deliver safe perioperative anaesthetic care to uncomplicated ASA 1-3 adult patients requiring elective and emergency surgery such as body surface surgery, appendicectomy and noncomplex gynaecological surgery under distant supervision Manage a list with uncomplicated ASA 1-3 adults for elective surgery under distant supervision DOPS Demonstrate use of the nerve stimulator to evaluate neuromuscular block (AGB_D01) A-CEX Demonstrates the ability to deliver safe perioperative anaesthetic care to ASA1-3 patients for straightforward surgical procedures e.g. body surface surgery, appendicectomy, ERPC (GU_BS_04) Administer anaesthesia to a patient with ischaemic heart disease (AGB_A06) ALMAT Demonstrates the ability to manage an elective surgical list with uncomplicated ASA 1-3 adults for straightforward body surface and lower abdominal surgery under distant supervision (GU_BS_05) CBD Discuss the effects and hazards of the pneumo-peritoneum induced for laparoscopic surgery (AGB_C05) Discuss the management of anaesthesia in the presence of common inter-current diseases e.g Asthma, COPD, Hypertension, IHD, Rheu A, Steroid therapy, Diabetes (AGB_C10) MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 1 A-CEX, 1 DOPs and 1 CBD 6

7 ENT, Maxillo-Facial and Dental Surgery Gain knowledge and skills of the perioperative anaesthetic care of patients undergoing minor to intermediate ear, nose and throat [ENT], maxilla-facial and dental surgery To be able to recognise the specific problems encountered with a shared airway and know the principles of how to manage these correctly Minimum clinical learning outcome: Must be acheived Deliver perioperative anaesthetic care to ASA 1-3 adults, and ASA 1 and 2 children over 5, for non-complex ear, adenotonsillar and nasal surgery under direct supervision A-CEX The provision of safe perioperative anaesthetic care for a wide range of commonly performed procedures, with good operating conditions and an appropriate level of analgesia, including: (EN_BS_02) - ENT procedures such as tonsillectomy, septoplasty and myringotomy - Common dental procedures such as extractions and apicectomies Administer anaesthesia for a shared airway procedure (AGB_A02) CBD Discuss how did the trainee dealt with anticipated problems where surgeon and anaesthetist shared the airway. (AGB_C02) MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 1 A-CEX, 1DOPs AND 1 CBD 7

8 Non-Theatre/Transfer To safely undertake the intra-hospital transfer of the stable critically ill adult patient for diagnostic imaging To understand the risks for the patient of having procedures in these sites To understand the responsibilities as a user/prescriber of diagnostic imaging services Minimum clinical learning outcome: Must be achieved Can maintain anaesthesia for stable critically ill adult patients requiring diagnostic imaging under distant supervision [in conjunction with their transfer as identified in Transfer Medicine] Safely manages the intra-hospital transfer of the critically ill but stable adult patient for the purposes of investigations or further treatment [breathing spontaneously or with artificial ventilation] with distant supervision A-CEX Can maintain anaesthesia for stable critically ill adult patients requiring diagnostic imaging under distant supervision (in conjunction with their transfer as identified in Transfer Medicine) (This may be done within ICM module) Safely manages the intra-hospital transfer of the critically ill but stable adult patient for the purposes of investigations or further treatment [breathing spontaneously or with artificial ventilation] with distant supervision MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 2 A-CEX, 2 DOPs and 2 CBDs 8

9 Obstetrics Learning outcome: To gain knowledge, skills and experience of the treatment of the healthy pregnant woman Minimum clinical learning outcomes: Must be achieved To pass the formal practical initial assessment of competence in obstetric anaesthesia and, having achieved this, be able to provide analgesia and anaesthesia as required for the majority of the women in the delivery suite To understand the management of common obstetric emergencies and be capable of performing immediate resuscitation and care of acute obstetric emergencies [e.g. eclampsia; pre-eclampsia; haemorrhage], under distant supervision but recognising when additional help is required All of the following twelve needs to be completed before the Obstetric Initial Assessment of Competence certificate can be signed off. A-CEX (Basic Competencies for Obstetric Anaesthesi Conduct epidural analgesia for labour (OB_BTC_A01) Conduct regional anaesthesia for caesarean section (OB_BTC_A02) Conduct general anaesthesia for caesarean section (OB_BTC_A03) DOPS (Basic Competencies for Obstetric Anaesthesi Top up epidural for labour analgesia (OB_BTC_D01) Top up epidural for caesarean section (OB_BTC_D02) Perform spinal anaesthesia (OB_BTC_D03) CBD Discuss how changes in the anatomy and physiology due to pregnancy influenced the conduct of anaesthesia (OB_BTC_C01) Discuss whether pregnancy influenced the choice of drugs used during anaesthesia (OB_BTC_C02) 9

10 Discuss how the conduct of general anaesthesia is affected by late pregnancy (OB_BTC_C03) Examine the case records of a patient that the trainee has anaesthetised for operative delivery in a situation where major haemorrhage might be expected. Discuss the factors that influence the likelihood of major obstetric haemorrhage, the precautions that should be taken to deal with it and the principles of its management. (OB_BTC_C04) Examine the case records of a patient with pregnancy associated hypertension that the trainee has treated. Discuss how this influences anaesthetic management. (OB_BTC_C05) Examine the case records of a patient for whom the trainee provided extradural analgesia for normal labour. Discuss the methods of pain relief available for normal delivery. (OB_BTC_C06) Initial Assessment of Competence in Obstetric anaesthesia certificate signed? 10

11 Orthopaedic Surgery To gain knowledge, skills and experience of the perioperative anaesthetic care of patients requiring orthopaedic surgery including patients with long-bone fractures To understand the relevance of diseases of bones and joints to anaesthesia To be able to recognise and manage the perioperative complications of orthopaedic surgery relevant to anaesthesia Minimum clinical learning outcome: Must be achieved Deliver perioperative anaesthetic care to uncomplicated ASA 1-3 adult patients for straightforward elective and emergency orthopaedic/trauma surgery to both upper and lower limbs, including Open Reduction Internal Fixation [ORIF] surgery [which includes fractured neck of femur], under distant supervision A-CEX or DOPS Demonstrates the provision of perioperative anaesthetic care for patients requiring orthopaedic surgery to the upper and lower limbs including but not exclusively: (OR_BS_01) - ORIF surgery including internal fixation of fractured neck of femur - Lower limb primary arthroplasty including patients in the lateral position Demonstrates correct assessment and perioperative management of the elderly patient with a hip fracture (OR_BS_03) Administer anaesthesia to an elderly patient [> 80 years] (AGB_A07) Conduct regional anaesthesia for surgery (AGB_A08) ALMAT Conduct an appropriate orthopaedic operating list (AGB_L02) MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 1 A-CEX, 1 DOPs AND 1 CBD OR ALMAT 11

12 Paediatrics Obtain knowledge of the principles underlying the practice of anaesthesia for children aged 1 year and older and the specific needs therein Have completed training in child protection Minimum clinical learning outcomes: Demonstrates correct management of the paediatric airway in the following ways [if case mix allows, down to one year of age, but at least down to five years of age]: - Is able to size airway devices correctly [i.e. oral airways and tracheal tubes] - Is able to insert airway devices correctly - Is able to ventilate an apnoeic child using a bag and mask +/- an oral airway - Is able to intubate a child correctly, using the most appropriate size tracheal tube, placed at the correct length Maintains anaesthesia in a spontaneously breathing patient via a facemask for a short surgical procedure [less than 15 mins] A-CEX (12-24 months) Make preoperative assessment of a fit child (PAB_A01) Administer anaesthesia to a child age>5 spontaneous ventilation (PAB_A02) Administer anaesthesia to a child age>5 controlled ventilation (PAB_A03) DOPS (12-24 months) Conduct IV Induction in a fit child (PAB_D01) Conduct inhalation induction of fit child (PAB_D02) Demonstrates ability to manage the airway correctly including selection of the correct masks, airways, laryngeal mask airways and tracheal tubes (PA_BS_06) SIM Demonstrates ability to perform paediatric resuscitation as described by the Resuscitation Council [UK] [S] (PA_BS_10) CBD Examine the case notes of a child the trainee has anaesthetised and discuss how differences in anatomy from the adult influenced the conduct of the anaesthetic. (PAB_C01) Discuss how the choice of drugs and drug doses differs from the adult. (PAB_C02) 12

13 Discuss airway management and the choice of suitable anaesthetic circuits for a child. (PAB_C03) All should complete Level 1 Child Protection Teaching MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 1 A-CEX, 1DOPs,1 CBD AND LEVEL 1 CHILD PROTECTION 13

14 Pain Medicine To be competent in the assessment and effective management of acute post-operative and acute non post-operative pain To acquire knowledge necessary to provide a basic understanding of the management of chronic pain in adults Minimum clinical learning outcomes: Must be achieved Competence in the assessment and effective management of acute post operative and acute non post operative pain To have an understanding of chronic pain in adults A-CEX Demonstrates the ability to assess, manage and monitor acute post operative and non post operative pain (PM_BS_01) DOPS Manages epidural analgesia by continuous infusion [6-12 months] AGB_D04 CBD Discuss how the trainee chose a regime for post operative pain relief and how they judged its adequacy (AGB_C15) Describes a basic understanding of chronic pain in adults (PM_BK_06) MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 1 A-CEX, 1 DOPs AND 1 CBD 14

15 Regional To become competent in all generic aspects of block performance Able to obtain consent for regional anaesthesia from patients Create a safe and supportive environment in theatre for awake and sedated patients Demonstrate knowledge of the principles of how to perform a number of regional and local anaesthetic procedures Be able specifically to perform spinal and lumbar epidural blockade Be able to perform some simple upper and lower limb peripheral nerve blocks under direct supervision Be able to use a peripheral nerve stimulator or ultrasound to identify peripheral nerves Demonstrate clear understanding of the criteria for safe discharge of patients from recovery following surgery under regional blockade Recognise that they should not attempt blocks until they have received supervised training, and passed the relevant assessments Accepts the right of patients to decline regional anaesthesia even when there are clinical advantages Minimum Clinical Learning outcome: Must be achieved Demonstrates safely at all times during performance of blocks including: marking side of surgery and site of regional technique; meticulous attention to sterility; selecting, checking, drawing up, diluting, and the adding of adjuvants, labelling and administration of local anaesthetic agents Establish safe and effective spinal and lumbar epidural blockade and manage immediate complications in ASA 1-2 patients under distant supervision Ability to establish a simple nerve block safely and effectively DOPS Demonstrates how to undertake a comprehensive and structured pre-operative assessment of patients requiring a subarchnoid blockade, perform the block and manage side effects/complications correctly (RA_BS_04) Demonstrates how to undertake a comprehensive and structured pre-operative assessment of patients requiring a lumbar epidural blockade, perform the block and manage side effects/complications correctly (RA_BS_05) Demonstrates how to perform some simple nerve blocks from amongst the following: Femoral; Ankle; Inguinal nerve blockade(ra_bs_11) A-CEX Conduct anaesthesia for surgery using spinal or epidural anaesthesia (RAB_A01) Manage the sedative regime of a patient undergoing surgery using regional anaesthesia (RAB_A02) 15

16 CBD Outlines the dangers of accidental intravenous administration of local anaesthetic drugs, signs, symptoms and management, including the role of intra-lipid (RA_BK_12) Discuss the choice of local anaesthetics & spinal opioids in the context of regional anaesthesia (RAB_C01) Discuss the innervation and spinal dermatomes of any regional anaesthetic block the trainee has used (RAB_C02) Discuss the management of the complications of spinal and epidural (including caudal) analgesia [associated hypotension, shivering, nausea & anxiety] (RAB_C03) Discuss the absolute and relative contraindications to regional blockade (RAB_C04) MINIMUM REQUIREMENT IN THIS UNIT IS COMPLETION OF 1 A-CEX, 1 DOPs AND 1 CBD 16

17 Sedation To gain a fundamental understanding of what is meant by conscious sedation and the risks associated with deeper levels of sedation To be able to describe the differences between conscious sedation and deeper levels of sedation, with its attendant risks to patient safety Understands the particular dangers associated with the use of multiple sedative drugs especially in the elderly To be able to manage the side effects in a timely manner, ensuring patient safety is of paramount consideration at all times To be able to safely deliver pharmacological sedation to appropriate patients and recognise their own limitations Minimum clinical learning outcome: Must be achieved Provision of safe and effective sedation to ASA 1 and 2 adult patients, aged less than 80 years of age using a maximum of two short acting agents A-CEX Demonstrates the ability to administer and monitor intravenous sedation to patients for clinical procedures (CS_BS_04) Manage the sedative regime of a patient undergoing surgery using regional anaesthesia (RAB_A02) CBD Discuss the trainee s choice and use of sedatives and tranquillisers (AGB_C04) MINIMUM REQUIREMENT IN THIS UNIT IS 1 A-CEX, 1 DOPs AND 1 CBD 17

18 Trauma and Stabilisation To understand the basic principles of how to manage patients presenting with trauma To recognise immediate life threatening conditions and prioritise their management Minimum clinical learning outcome: Must be achieved Understands the principles of prioritizing the care of patients with multi-trauma including airway management SIM or DOPS Demonstrates correct emergency airway management in the trauma patient including those with actual or potential cervical spine damage [S] (MT_BS_02) Assess a patient s Glasgow Coma Scale rating and advise appropriate safe levels of monitoring and care [3-6 months] (AGB_D02) Perform a primary and secondary survey of an injured patient [may be done in simulator] (AGB_D03) CBD Discuss the management of cervical spine injuries (AGB_C24) MINIMUM REQUIREMENT IN THIS UNIT IS 1 A-CEX, 1 DOPs AND 1 CBD OR SIM SESSION 18